ESC Andreas Grüntzig Lecture on Interventional Cardiology: Prof. Cindy Grines
28 Aug 2021
History of primary PCI
The presenter of this year’s ESC Andreas Grüntzig Lecture on Interventional Cardiology, Professor Cindy Grines (Chief Scientific Officer of Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA), changed the outlook for myocardial infarction (MI) patients with her pioneering work on percutaneous coronary intervention (PCI).
How did you come to specialise in interventional cardiology?
During my training I quickly gravitated towards cardiology because not only did it seem to be a logical and scientific specialty but it was, and still is, a very dynamic field with a lot of opportunity for development.
The decision to specialise in interventional cardiology came about almost by chance. I was intending to be a non-invasive cardiologist but when I started my cardiology training at the University of Michigan, I found that it was a hotbed of this relatively new and exciting discipline, interventional cardiology. I learned a huge amount there and worked with several people who had a profound influence on the direction of my career. In addition, with interventional cardiology, you see the effects on patients quickly – you are quite literally saving their lives.
Tell us something about your lecture topic
My lecture talks about the evolution of primary angioplasty for ST-segment elevation acute MI (STEMI). It draws parallels with the experience of Andreas Grüntzig, who had to overcome many hurdles to persuade people that interventional cardiology procedures were safe and effective. When I was a cardiology fellow, we were allowed to perform angioplasty in patients with an MI only after thrombolytics. This meant that correction of arterial occlusion could be delayed by over an hour. We suggested that simultaneously combining the two methods of treatment, or eliminating thrombolytic therapy altogether, could improve patient outcomes and we set about conducting a series of studies to investigate this.
Our findings were met with a great deal of hostility and criticism and, even after additional studies confirmed the results we had shown, the role of primary angioplasty continued to be questioned for many years. Eventually, it became a widely accepted approach and it is gratifying to note that it is now the standard-of-care treatment for patients with acute MI around the world.
What are the current challenges in interventional cardiology?
Cardiogenic shock still poses a real problem for treatment. Outcomes are poor and the reasons for this are unclear. It might be that patients respond differently at different stages of the condition. Accordingly, along with the Society for Cardiovascular Angiography and Interventions, we produced a consensus document defining five stages of shock.1 It is possible that for patients at stage A (‘at risk’), it is too early for interventions to prevent the development of shock, whereas for those at stage E (‘extremis’), it may be too late for intervention. We are now investigating this further to try to determine which patients might benefit and at what point we need to intervene aggressively.
Where do you think research is heading in the future?
Perhaps one of the most difficult problems we face is complex coronary disease in general, particularly in patients with diabetes. We need to understand why patients with multiple lesions do better with bypass surgery. For instance, it could be that the techniques and antithrombotic medications we are using are suboptimal, or perhaps diabetes medications contribute to a worse outcome with angioplasty.
Calcification poses some real technical difficulties, and it is reassuring that we are now seeing advances in this area, such as the intravascular lithotripsy shock-wave therapy that has recently been approved in the US. Bifurcations and chronic total occlusions are additional problem areas, but there are some promising treatments emerging. Interventional cardiology continues to be an exciting and fast-moving field!
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1. Baran DA, et al. Catheter Cardiovasc Interv. 2019;94:29–37.